The recent Medicaid expansion, brought about by the Affordable Care Act (ACA), has paved the way for more than 13 million Californians to enroll in the program; another 1.2 million residents have enrolled in qualified health plans (QHPs) through Covered California, the state’s health insurance marketplace.
In connection with these health insurance expansions, California launched an ambitious effort to collect and report key data on the pathways to publicly subsidized health care coverage. The data include information on applications for coverage, eligibility determinations, enrollment, and renewals for Medicaid and QHP coverage. California was one of the first states to attempt to report this information publicly. The systematic understanding that the state is building about the flow of enrollment, the stability of coverage, and the diversity of enrollees lays the groundwork for fully understanding and anticipating the challenges of enrolling people in insurance and connecting them to care.
Launching The Reporting Effort
In 2013, California was anticipating the Medicaid coverage expansion and the launch of Covered California, and it enacted legislation (AB X1-1) that required quarterly reporting on the application and enrollment processes for publicly subsidized health insurance. The goal was to be transparent about how people enroll in and move between the state Medicaid program, Medi-Cal, and the QHPs made available through Covered California.
In 2014 and 2015, the California Health Care Foundation and Mathematica Policy Research partnered with the California Department of Health Care Services (DHCS) and Covered California to support the launch of a public reporting effort that would meet the legislative requirements and routinely provide data about pathways to public insurance.
Key Findings
To date, California has published four reports that cover the period from October 2013 through September 2015, and several noteworthy findings have emerged from the early data.
The open enrollment period boosts enrollment in QHPs and Medi-Cal
Even though people may enroll in Medi-Cal year-round, the jump in the number of applications that come in during Covered California’s open enrollment period (see chart below) increased enrollment in both programs. Covered California’s second open enrollment period ran from November 15, 2014, through February 15, 2015.
From January to March 2015, eligibility determinations for Medi-Cal rose 28 percent relative to the last quarter of 2014, and the number of people who selected a QHP increased 85 percent. The data suggest that, for both programs, the state should be prepared to manage large fluctuations in the volume of applications, including spikes at the end of Covered California’s open enrollment periods.
Number of applications and individuals in the applications processed through the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS): January 2014–March 2015
Source: California Eligibility and Enrollment Report: Insurance Affordability Programs. Reporting period January 2015 through March 2015.
Enrollment is more persistent over time than expected
Seventy-seven percent of Medi-Cal beneficiaries whose eligibility was reviewed during the first quarter of 2015 (the annual renewal period) remained eligible for coverage. Less than 1 percent of these renewals reflected reinstatements during the 90-day period following discontinuance of coverage, which suggests that most people who renewed did so before their coverage end date.
Similarly, the vast majority of individuals enrolled in QHPs retained their coverage (92 percent) during the first annual renewal (the second open enrollment period). Approximately 94 percent of those who renewed stayed with the same insurance carrier (35 percent by deliberately choosing that carrier after exploring options and 65 percent by default).
Although these renewal rates are higher than initial predictions, more years of data are needed to assess whether this pattern will continue or whether it is a function of (1) the processes for renewing and (2) the types of people who enrolled at the beginning of the coverage expansion. However, if insurance coverage does remain relatively stable over time, it will strengthen the incentive for issuers and payers to invest in preventive health services and could lower administrative costs.
Shifts in common eligibility codes for Medi-Cal beneficiaries have implications for tracking and research
The ACA established the modified adjusted gross income (MAGI) standard as the basis for determining Medicaid eligibility. Under pre-expansion eligibility rules, there were many pathways other than the MAGI standard through which individuals could qualify for Medicaid, based on household income in combination with other characteristics (categorical eligibility) such as age or disability status.
These non-MAGI pathways still exist, but many beneficiaries who would have been classified under the non-MAGI codes are instead eligible under MAGI rules. Although this change streamlines enrollment for consumers, it introduces challenges for those who want to study similar non-MAGI individuals over time. Researchers will need to consider using criteria aside from eligibility codes to identify beneficiaries of interest.
Change in total Medi-Cal enrollment under MAGI and Non-MAGI eligibility codes, December 2014 to March 2015
Source: California Eligibility and Enrollment Report: Insurance Affordability Programs. Reporting period: January 2015 through March 2015.
Practical Lessons for Other States
In addition to the enrollment and eligibility patterns mentioned above, California’s experience offers several practical lessons for other states that are thinking about implementing more robust reporting projects.
Defining meaningful reporting measures and producing these data require a substantial investment in staff time
DHCS and Covered California have dedicated staff to their quarterly reporting effort, including programmers who can query complex databases and policy experts who help to (1) define measures that reflect noteworthy policy distinctions and (2) examine trends in data against the timing of known policy changes to look for evidence of effects. Routine meetings between state officials responsible for the report and consumer advocates act as a vehicle for both collecting feedback on stakeholder priorities and shaping the reports.
Barriers to integrating data systems can limit a state’s ability to measure movement between programs
California’s legislature wants to know the outcome of the renewal process, including whether a beneficiary moves to another public plan or loses eligibility entirely. To report renewal outcomes, Covered California must know whether QHP cases that appear to be Medi-Cal eligible at renewal actually become Medi-Cal enrollees after they are referred to DHCS.
Conversely, DHCS must know whether individuals in cases that are referred to Covered California actually select a QHP and make their first premium payment to activate the coverage. This type of tracking is not yet possible because it requires the development of a unique beneficiary identifier that can be maintained as the beneficiary changes coverage over time. California is in the process of developing a data warehouse that can accommodate this type of query, but at present, neither DHCS nor Covered California can track the resolution of referrals.
The challenge of communicating results is as formidable as specifying and producing the data
California has sought to balance the pressure to make information simple enough for broad audiences but detailed enough to engage well-informed stakeholders. For each new data element that the state added, a plain language explanation of the associated technical processes and data limitations was required.
In addition, coverage status is dynamic; it reflects consumer choices, changing consumer household circumstances, and administrative processing. Unless public data releases are well coordinated both within and between agencies, these inherent features of coverage-related data will look like conflicting information to some stakeholders. Officials must be prepared to explain these nuances, which inevitably color the point-in-time snapshots of an eligibility and enrollment system.
Systematic monitoring of coverage dynamics enables data-driven planning
Developing a set of measures that capture coverage dynamics—and not just a snapshot of those who successfully enroll—would enhance the internal management capacity of any state, whether or not it chooses to pursue a public reporting project. By examining the gaps between applicants and eligible individuals, officials can begin to understand more about the remaining pockets of uninsured — or underinsured. By examining the stability of coverage over time, officials can build some understanding of the degree to which enrollees might engage in health improvement programs where benefits accrue in a future year.
Most importantly, by understanding movement between Medicaid and the Marketplaces, officials have the tools to spot breakdowns in the seamless coverage continuum envisioned by the ACA, leaving them better equipped to brainstorm creative solutions to those shortfalls. While making these measures public adds a layer of communication complexity, in doing so a state also gains the insights of a broad range of stakeholders who can bring a fresh perspective to interpreting data trends and identify appropriate solutions.
More to Learn
Despite the challenges involved in developing a set of measures and releasing those through public reports, California now has the foundation for continuous improvement in the business processes that underlie pathways to insurance coverage. For example, as the Marketplace matures, are there changes in the choice of enrollment pathway, and should outreach, marketing, and staffing resources shift accordingly? Do some demographic groups that submit applications go on to complete enrollment at higher rates than others, suggesting the need for enhanced language resources or other changes in consumer supports?
The AB X1-1 reports also can identify local variation: in California, 58 county offices play a key role in administering the Medi-Cal program, offering a natural place to look for best practices. Covered California also engages with agent, broker, and assister communities that are distributed throughout the state and may vary in their local practices. When eligibility and enrollment outcomes vary across counties, DHCS and Covered California can examine whether there are policy or process differences that might be driving different outcomes. For example:
- Are individuals in some counties more likely to submit an application that is accurate and complete enough for an eligibility determination? If so, are there best practices in the local county office, assister, broker, and/or agent communities that can be replicated in other counties?
- Do applicants for temporary Medi-Cal coverage via hospital presumptive eligibility go on to complete full applications at the same rate in all counties and across participating hospitals? If not, would educating providers result in greater consistency?
- Does the rate at which individuals actively choose to switch health plans at renewal vary, offering an opportunity to examine local variation in consumer coaching around active plan choice?
As California’s reporting project continues to evolve, the insight gained and questions raised through the state’s efforts can inform measurement, monitoring, and reporting strategies in other states, and within the Centers for Medicare & Medicaid Services as it maintains and updates its federal reporting requirements and public reports.
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